An Innovative Stump Stenting Technique for Dissection of Cholecystocystic Stump after Subtotal Cholecystectomy in Difficult Gallbladders to avoid complications associated with the Residual Gallbladder Stump. A Prospective Study

Abstract

Background: The management of difficult gallbladders often need some innovative techniques and cannot always be done by standard antegrade dissection as there can be dense assimilated adhesions due to recurrent chronic inflammatory process causing distortion in the anatomy of calot’s triangle, thereby increasing the risk of biliovascular injuries. So the only bail out option in such situation becomes subtotal cholecystectomy by some other techniques to avoid biliary and vascular injuries. But the residual cholecystocystic stump following subtotal cholecystectomy is associated with certain complications like stump cholecystitis, stump calculi and post cholecystectomy syndromes.Objectives: To avoid the complications of residual cholecystocystic stump, we go one step beyond subtotal cholecystectomy by stenting the residual GB stump with feeding tube or guide wire which delineates the orientation of cystic as well as common bile duct and facilitates further dissection of cholecystocystic stump to an optimum extent which completely abolishes the residual cholecystocystic stump and also makes it complete cholecystectomy and no further residual stump and its associated complications.Methods: The study conducted in postgraduate department of surgery Government Medical College Jammu and in a corporate hospital of Jammu over a period of three years from January 2018 to January 2021. A total of 83 patients of difficult gallbladders associated with frozen and distorted calot’s triangle were included in the study.Results: During postoperative period and follow up period in our study of 83 patients of difficult gallbladders with frozen calot’s triangle, we have a bile leak in five patients, in two due to missed CBD stone and consequently slipping of cystic duct clips. ERCP with clearance of CBD stones were done followed by stenting of CBD and patient settled within 3-5 days. Rest of three were from accessory duct which also settled spontaneously within 3-7 days. No major bile duct injury occurred. Port site infection occurred in 8 patients, 3 confirmed as atypical mycobacterial infections. 11 patients had systemic complications which settled with expectant management. Two elderly patients of perforated gallbladders died due to systemic complications. Rest of the patients had uneventful and smooth recovery.
Conclusion: Stenting of residual cholecystocystic stump followed by dissection is a viable, effective and safe option to convert subtotal cholecystectomy into complete cholecystectomy and to avoid the long term complications associated with residual gallbladder stump.